Chapitre 3 – L’évolution des lois antidopage
I. Apparition et croissance du cadre légal de la lutte antidopage
2. La deuxième évolution : une nouvelle gouvernance de la lutte contre le dopage
2.1. Une restructuration institutionnelle
O idoso apresenta alterações anatômicas e fisiológicas associadas ao envelhecimento, maior incidência de doença pulmonar obstrutiva crônica, doença renal e doença arterial em outros territórios, principalmente cerebral. É freqüente a presença de déficit nutricional, diminuição da resposta inumológica celular e humoral, e declínio da capacidade funcional e cognitiva. Todos estes fatores são avaliados na indicação cirúrgica. A mortalidade cirúrgica pode ser estimada por meio dos escores de risco, dentre os quais o Bernstein- Parsonnet e o Euroscore são os mais utilizados, sendo a idade um marcador independente de risco.
Em pacientes multiartertiais com quadro clínico estável, 7 estudos (RITA 2, ACME, ACME 2, MASS, MASS 2, AVERT e TIME) compararam a ICP e o tratamento clínico otimizado. Observaram que não existem diferenças na mortalidade e na evolução para IAM, sendo a ICP mais efetiva no alívio da angina, enquanto a revascularização de repetição foi mais frequente no grupo clínico em três estudos e semelhante em outros três. Recentemente, o estudo COURAGE134 apresentou
resultados semelhantes, demonstrando que em pacientes estáveis o tratamento clínico otimizado deve ser considerado, especialmente nos idosos de baixo e médio risco.
Uma série de estudos comparou CRM e ICP em pacientes multiarteriais,. Uma metanálise de 4 estudos (ARTS, ERACI- II, MASS-II, E SoS) em que foram utilizados stents140 mostrou
sobrevida semelhante, mas a sobrevida livre de infarto, AVC e revascularização de repetição em 5 anos favoreceu a CRM (77%) em relação à ICP (60%). Como os pacientes nesses estudos apresentavam baixo percentual de obstruções multiarteriais (35%-38%) e função ventricular esquerda normal, questionou-se se estes pacientes refletiam o mundo real. Para diminuir esse viés, vários estudos não randomizados, porém com ajuste de risco, avaliaram os bancos de dados do Erasmus Medical Center de Rotterdam, do Washington Hospital Center, e o extenso banco de dados do estado de Nova York, com o objetivo de comparar a CRM com a ICP com stent convencional141-143. Nesse último banco de
dados, foi realizado novo estudo para avaliar a ICP com stent farmacológico144. Esses estudos confirmaram os resultados
prévios – com a CRM, ocorre sobrevida com menor ocorrência de eventos, principalmente revascularizações de repetição, e maior sobrevida ao fim de um, três ou 8 anos nos pacientes com obstruções bi e triarteriais.
Existem evidências de que a CRM apresenta vantagens em relação à ICP nos pacientes multiarteriais, porém no idoso a CRM associa-se a maior mortalidade hospitalar. Nessa faixa etária, a escolha do tratamento deve ser individualizada, considerando o risco da doença, a possibilidade ou não da ICP, o risco da CRM, a presença de comorbidades, a expectativa de vida e a preferência do paciente.
Graus de recomendaçã/níveis de evidência na indicação da cirurgia de revascularização do miocárdio na angina estavel145
Grau de recomendação I, nível de evidência C:
a) Lesão crítica do tronco de coronária esquerda. b) Doença crítica equivalente de tronco: ≥ 70% de estenose das artérias descendente anterior e circunflexa.
c) Doença crítica triarterial com fração de ejeção do VE < 50%.
d) Doença crítica biarterial com fração de ejeção do VE < 50% ou extensa isquemia.
e) Angina incapacitante, apesar do tratamento clínico otimizado e risco aceitável da CRM.
f) Lesões valvares ou sequelas no ventrículo que precisam ser corrigidos.
Grau de recomendação IIa, nível de evidência C:
a) Lesão crítica proximal da artéria descendente anterior, com isquemia extensa ou FEVE < 50%.
b) Lesão crítica biarterial sem acometimento da artéria descendente anterior, mas com miocárdio viável e isquemia.
Grau de recomendação III, nível de evidência C:
a) Lesão uni ou biarterial, sem doença da artéria descendente anterior, sintomas discretos ou incaracterísticos ou que não receberam tratamento clínico adequado, além de:
• pequena área de músculo viável; • sem isquemia nos exames funcionais.
b) Lesão de artéria coronária limítrofe (50%-60%), exceto no tronco da coronária esquerda.
c) Lesão de artéria coronária menor que 50%.
Recentes avanços na CRM, especialmente a cirurgia minimamente invasiva e a cirurgia sem circulação extracorpórea, diminuíram os riscos do procedimento nos idosos. Serviços auxiliares, tais como nutrição, enfermagem e fisioterapia são componentes importantes nos cuidados pós-operatórios para diminuir as morbidades e mortalidade.
Em geral, a idade não é contraindicação para a CRM, mas é necessária uma cuidadosa avaliação pré-operatória e um suporte pós-operatório eficiente para o paciente.
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